CDIP PRACTICE REAL EXAM 2 Q AND A
STUDY SHEET 2026 FULL SOLUTION VIEW
AHEAD
◉ A clinical documentation specialist (CDS) is employed at ABC
hospital. She has been consistently having conversations with the
hospitalists on what they should document on every patient that
presents with fever and receives antibiotics. As director, you should:
a.Review the AHIMA Query Brief with the CDS
b.Review the escalation policy with the CDS
c.Ensure all staff have the same proactive approach
d.No attention to this area is needed
Answer: a Review the AHIMA Query Brief with the CDS. Verbal
queries should contain the same clinical indicators and follow the
same format as written queries to ensure compliance and
consistency in policy and process. Documentation of the verbal
query may be condensed to reflect the stated information, but
should identify the clinical indicators that support the query as well
as the actual question posed to the practitioner. Verbal queries
should be documented at the time of the discussion or immediately
following (AHIMA 2013a, 50-53).
,◉ The CDS manager has been asked to assist with assessing or
managing data quality for internal external customers. This role is
called the:
a.Chief Information Officer
b.HIM director
c.Quality analyst
d.Data manager
Answer: d Data manager. When tasked with assessing or managing
data quality, an HIM professional must first understand who the data
consumers are. This involves making a list of all of the internal and
external consumers. Assessing the needs of data consumers is
challenging; a good data manager would ask the data consumer how
they use the data rather than what their needs are. The data
manager must take a controlled and careful approach to collecting
data for consumer needs. It will be impossible for the data manager
to meet all the needs of all of the data consumers (Fenton and
Biedermann 2014, 114-115).
◉ A CDI program should be governed by policies and procedures.
These policies and procedures should be developed with the
assistance of other departments affected by clinical documentation,
including compliance, case management, and what other
department?
a.Information systems
b.Process improvement
c.Health Information Management (HIM)
,d.Finance
Answer: c HIM These policies and procedures should be developed
with the assistance of other departments affected by clinical
documentation, including compliance, case management, and HIM
(AHIMA 2013b).
◉ Providers should maintain queries:
a.Indefinitely
b.Based on their facility policy
c.Never
d.Until the patient expires
Answer: b Based on your facility policy. Retention of the query varies
by healthcare organization. First, an organization must determine if
the query will be part of the health record. If the query is not part of
the health record, then the organization must decide if the query is
kept as part of the business record or only the outcome of the query
is maintained in a database (AHIMA 2013b).
◉ The new CDI manager has decided the query will become a part of
the health record stating this is required.
a.The query has to be a part of the health record
b.An organization must determine if the query will be part of the
health record
c.The query should be disposed of after completion
, d.All queries should be verbal
Answer: b It is the decision of an organization of how to maintain
queries and whether to include them as part of the health record. .
Retention of the query varies by healthcare organization. First, an
organization must determine if the query will be part of the health
record. If the query is not part of the health record, then the
organization must decide if the query is kept as part of the business
record or only the outcome of the query is maintained in a database
(AHIMA 2013b).
◉ Erin is the HIM director at Anywhere Hospital. She is teaching a
class to clinicians about proper documentation in the health record.
Which of the following would she not instruct them to do?
a.Obliterate errors
b.Leave existing entries intact
c.Label late entries as being late
d.Ensure the legal signature of an individual making a correction
accompanies the correction
Answer: a Any corrections to the record must be entered properly. In
paper records, the provider should draw a single line through the
error, add a note explaining the error, initial and date the error with
the date it was discovered, and enter the correct information in
chronological order. For electronic entries, a procedure should be
followed that explains how to correct errors and enter addenda to
the health record (Shaw and Carter 2014; LaTour et al. 2013, 264).
STUDY SHEET 2026 FULL SOLUTION VIEW
AHEAD
◉ A clinical documentation specialist (CDS) is employed at ABC
hospital. She has been consistently having conversations with the
hospitalists on what they should document on every patient that
presents with fever and receives antibiotics. As director, you should:
a.Review the AHIMA Query Brief with the CDS
b.Review the escalation policy with the CDS
c.Ensure all staff have the same proactive approach
d.No attention to this area is needed
Answer: a Review the AHIMA Query Brief with the CDS. Verbal
queries should contain the same clinical indicators and follow the
same format as written queries to ensure compliance and
consistency in policy and process. Documentation of the verbal
query may be condensed to reflect the stated information, but
should identify the clinical indicators that support the query as well
as the actual question posed to the practitioner. Verbal queries
should be documented at the time of the discussion or immediately
following (AHIMA 2013a, 50-53).
,◉ The CDS manager has been asked to assist with assessing or
managing data quality for internal external customers. This role is
called the:
a.Chief Information Officer
b.HIM director
c.Quality analyst
d.Data manager
Answer: d Data manager. When tasked with assessing or managing
data quality, an HIM professional must first understand who the data
consumers are. This involves making a list of all of the internal and
external consumers. Assessing the needs of data consumers is
challenging; a good data manager would ask the data consumer how
they use the data rather than what their needs are. The data
manager must take a controlled and careful approach to collecting
data for consumer needs. It will be impossible for the data manager
to meet all the needs of all of the data consumers (Fenton and
Biedermann 2014, 114-115).
◉ A CDI program should be governed by policies and procedures.
These policies and procedures should be developed with the
assistance of other departments affected by clinical documentation,
including compliance, case management, and what other
department?
a.Information systems
b.Process improvement
c.Health Information Management (HIM)
,d.Finance
Answer: c HIM These policies and procedures should be developed
with the assistance of other departments affected by clinical
documentation, including compliance, case management, and HIM
(AHIMA 2013b).
◉ Providers should maintain queries:
a.Indefinitely
b.Based on their facility policy
c.Never
d.Until the patient expires
Answer: b Based on your facility policy. Retention of the query varies
by healthcare organization. First, an organization must determine if
the query will be part of the health record. If the query is not part of
the health record, then the organization must decide if the query is
kept as part of the business record or only the outcome of the query
is maintained in a database (AHIMA 2013b).
◉ The new CDI manager has decided the query will become a part of
the health record stating this is required.
a.The query has to be a part of the health record
b.An organization must determine if the query will be part of the
health record
c.The query should be disposed of after completion
, d.All queries should be verbal
Answer: b It is the decision of an organization of how to maintain
queries and whether to include them as part of the health record. .
Retention of the query varies by healthcare organization. First, an
organization must determine if the query will be part of the health
record. If the query is not part of the health record, then the
organization must decide if the query is kept as part of the business
record or only the outcome of the query is maintained in a database
(AHIMA 2013b).
◉ Erin is the HIM director at Anywhere Hospital. She is teaching a
class to clinicians about proper documentation in the health record.
Which of the following would she not instruct them to do?
a.Obliterate errors
b.Leave existing entries intact
c.Label late entries as being late
d.Ensure the legal signature of an individual making a correction
accompanies the correction
Answer: a Any corrections to the record must be entered properly. In
paper records, the provider should draw a single line through the
error, add a note explaining the error, initial and date the error with
the date it was discovered, and enter the correct information in
chronological order. For electronic entries, a procedure should be
followed that explains how to correct errors and enter addenda to
the health record (Shaw and Carter 2014; LaTour et al. 2013, 264).
